Cholera medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editors-In-Chief: Priyamvada Singh, MBBS [3]

Overview

Choleria is a severe bacterial gastrointestinal, diarrheal disease. In its most severe forms, cholera is one of the most rapidly fatal illnesses known. A healthy person may become hypotensive within an hour of the onset of symptoms and may die within 2-3 hours if no treatment is provided. More commonly, the disease progresses from the first liquid stool to shock in 4-12 hours, with death following in 18 hours to several days without rehydration treatment.

Medical therapy

Summary of the treatment

• Rehydrate with ORS or IV solution depending on the severity. Rehydration involves replenishment of the lost fluids and then maintenance of the fluid balance
• Maintain hydration and monitor frequently the hydration status
• Give antibiotics for severe cholera cases

Management of cholera patients (table 1)

Mental status	Eyes	Thirst	Skin pinch	Conclusions	Management
Normal, Alert	Normal, hydrated	Normal	Goes down quickly (spontaneously)	No / Mild dehydration	Child < 2 years: 50–100 ml (1/4–1/2 cup)ORS solution. Up to approximately 1/2 litre a day. Child between 2 and 9 years: 100–200 ml. Up to approximately 1 litre a day. Patient of 10 years of age or more as much as wanted, up to approximately 2 litres a day.
Irritable	Sunken	Drink eagerly	Goes back slowly (< 2 sec)	Some / Moderate dehydration (in case if 2 of the symptoms are present)	Give Oral Rehydration Salt in the amount recommended in below in table 2 Nasogastric tubes can be used for rehydration when ORS solution increasesvomiting and nausea or when the patient cannot drink Monitor the patient frequently
Lethargic, unconscious or floppy	Sunken, absence of tears	Drinks poorly	Goes back slowly (> 2 sec)	Severe dehydration (in case if 2 of the symptoms are present)	Put an IV drip to start intravenous rehydration In case this is not possible, rehydrate with ORS Give IV drips of Ringer Lactate or if not available cholera saline (or normal saline) 100 ml/kg in three-hour period (in 6 hours for children aged less than 1 year) Start rapidly (30ml/kg within 30 min) and then slow down. Total amount per day: 200 ml/kg during the first 24 hours

Management of patients with some/moderate dehydration (table 2)

Age	Less than 4 months	4–11 months	12–23 months	2–4 years	5–14 years	15 years
Weight	Less than 5 kgs	5–7.9 kg	8–10.9 kg	11–15.9 kg	16–29.9 kg	30 kg or more
ORS solution in ml	200–400	400–600	600–800	800–1200	1200–2200	2200–4000

Maintenance of hydration & monitoring the patient

Reassess the patient for signs of dehydration regularly during the first six hours:

• Number and quantity of stools and vomit in order to compensate for the loss of body fluids
• Radial pulse: if it remains weak, IV rehydration has to be continued.

Method to prepare home made ORS solution

• If ORS sachets are available: dilute one sachet in one litre of safe water
• Otherwise: Add to one litre of safe water:
  • Salt 1/2 small spoon (2.5 grams)
  • Sugar 6 small spoons (30 grams)
• Try to compensate for loss of potassium (for example, eat bananas or drink green coconut water)

Antibiotics

• Use antibiotics in severe cases only.
• Doxycycline single dose 300 mg or tetracycline 12,5 mg/kg 4 time/day for 3 days
• Young children: erythromycin 12,5 mg/kg 4 time/day for 3 days
  • for children below 6 months of age: 10 mg daily for 10 days add zinc
  • for children 6 months to 5 years of age: 20mg daily for 10 days add zinc

Nutrition

• Proper attention on nutrition is important as patients with cholera often ignore nutrition due to diarrhea and vomiting. This may lead to hypoglycemia and associated complications like seizure, coma and even death in pediatrics population.
• Provide frequent small meals with familiar foods during the first two days rather than infrequent large meals
• Breastfeeding of infants and young children should continue

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